WIPA Recipients Current Versions

Intake for WIPA Grantee Example
WIPA Initial Contact and Demographics
*First Name
Middle Initial
*Last Name
Suffix
I

II

III

IV

Jr.

Sr.

Address 1
Apt./Suite
ZipCode
E-Mail
Home Phone
Cell Phone
Ext
Work Phone
TTY?
No

Yes

TTY/Videophone number/IP address
SSN
DOB
Gender
Marital Status
Common Law

Divorced

Domestic Partner

Married

Separated

Single

Widowed

Case Number
*Benefits received at intake
Private Disability Insurance

SSDI

SSI

Veterans benefits

Workers Compensation

*How did customer hear about the WIPA?
Community Rehabilitation Provider

Developmental Disability Agency

DOL One-Stop Center

Employment Network

Housing Agency

Internet

* A demographic with an asterisk is a required field.
09/11/2009

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Intake for WIPA Grantee Example
Maximus

Medicaid

Mental Health Agency

Newspaper

Other

Other WIPA Outreach

Receipt of a Ticket

SSA Field Office

Television

Veteran Service Organization

Vocational Rehabilitation

Walk-In

WISE

*Employment status at intake
Considering employment

Currently working

Job offer pending

Looking for employment

Self employed

Self-Reported Primary Disability
Blind or Visual Impairment

Cancer/Neoplasm

Cognitive/Developmental Disability

Hearing, Speech, and Other Sensory
Impairment

Infectious Disease

Injury

Mental and Emotional Disorders

Non-Spinal Cord Orthopedic
Impairment

Other

Spinal Cord Injury

System Disease

Traumatic Brain Injury

If OTHER primary disability, please specify:
Self-Reported Secondary Disability
Blind or Visual Impairment

Cancer/Neoplasm

Cognitive/Developmental Disability

Hearing, Speech, and Other Sensory
Impairment

Infectious Disease

Injury

Mental and Emotional Disorders

Non-Spinal Cord Orthopedic
Impairment

Other

Spinal Cord Injury

System Disease

Traumatic Brain Injury

If OTHER secondary disability, please specify:
Is beneficiary his her own payee?
No

Yes

Name of Representative Payee
Representative Payee Address
Telephone number of Payee
Special Language Consideration
English as a second language

Other special language needs

Sign language interpreter

English Proficiency
Understand neither written nor verbal
communication

Understand written English
communication

Understands both verbal and written
English communication

Understands verbal English
communication

* A demographic with an asterisk is a required field.
09/11/2009

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Intake for WIPA Grantee Example
Level of Education at Intake
Associate/2 year degree

Bachelor's degree

Doctorate degree

HS diploma or equivalent

Less than HS diploma

Master's degree

Other degree or certification

Some college

Health Status at Intake (self-identified)
Fair

Good

Poor

Very Good

Beneficiary services funding source
Other funds

State funds

WIPA funds

AssignedStaffID
Priority Level
Basic

High

Low

Medium

* A demographic with an asterisk is a required field.
09/11/2009

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* Indicates a required field.
1. *PARTICIPANT NAME:
2. *CONTACT LOCATION/METHOD (SELECT ONE)
• Follow-up contact
• Initial Contact
3. *DATE OF CONTACT (MM/DD/YYYY)
4. DATE OF NEXT CONTACT (MM/DD/YYYY)
5. *TIME SPENT ON CONTACT (MINUTES):

6. CASE NOTES (CALLED “NOTES IN ETO”) (TEXT BOX):

Paperwork Reduction Act References
I&R Program Home Program

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WIPA Program Home Page:

See revised Privacy Act and Paperwork
Reduction Act Statements below.

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SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number is 09600629. OMB approval expires on ____________. We estimate that it will take about 5
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

SOCIAL SECURITY

WORK INCENTIVES PLANNING AND ASSISTANCES (WIPA)
Privacy Act Notice
The Work Incentives Planning and Assistances (WIPA) program is established by the Social
Security Administration (SSA) under a law called the Ticket to Work and Work Incentives
Improvement Act of 1999. Under the WIPA program, SSA gives money to organizations so
they can provide SSA beneficiaries with accurate information about work incentives and benefits
planning. SSA will be collecting information from these organizations, including the names and
Social Security numbers of the SSA beneficiaries that the organizations serve, so SSA can
evaluate how the WIPA program is working.
The information you provide is voluntary. However, failure to provide the requested information
may limit your ability to participate in the WIPA program.
Any information reported as part of the WIPA program will not become part of your Social
Security record. The information will not be reported to the SSA office that makes eligibility
determinations. You are responsible for reporting income or changes in status to the SSA office.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Systems of Records Notice 60-0218 (Disability Insurance and
Supplemental Security Income Demonstration Projects and Experiments System). The Notice,
additional information about this form, and any other information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.

SOCIAL SECURITY ADMINISTRATION

BALTIMORE MD 21235-0001